Via Research Recognition Day 2024 VCOM-Carolinas

Educational Reports

Supine Time Standardization In An Interventional Radiology Practice – A Quality Improvement Project Kyle Kleiman, OMS-III; Chinedum Nkemakolam, OMS-III; Austin Molina, OMS-III; TJ Mack, RN; Richard Harp, MD; Kristine Lombardozzi, MD. Edward Via College of Osteopathic Medicine – Carolinas; Spartanburg Regional Health System.

Context

Results

Discussion & Conclusions

Postdural puncture headache (PDPH) can be a complication of dura-puncturing procedures, such as lumbar puncture. The incidence of PDPH varies depending on risk factors, but it is generally around 11 percent when a standard, traumatic needle is used. Lying supine after any dura-puncturing procedure has historically been used to avoid PDPH. Physicians typically have their patients lay supine for a variable amount of time following a procedure to avoid such complications. There is data to suggest that extensive duration (4 hours) of bed rest has diminishing returns and potentially deleterious effects compared to short duration (1 hour) in lumbar puncture. There is also data to show that 1 hour of bedrest leads to a lower incidence of PDPH compared to 30 minutes regarding minimum length. Risk factors affecting rates of PDPH have been studied in the past. Some potential risk factors for PDPH following a dura puncturing procedure include younger women with previous headache history, body mass index, and needle type. Objective To examine the relationship of supine time on PDPH and create a standardized approach to prescribing supine time to each patient. All patients (≥18 years of age) undergoing a dura puncturing procedure in the department of Interventional Radiology at SRHS from July 1, 2022, to Dec 31, 2022, were screened for eligibility for inclusion. Pregnant women and prisoners were excluded. A sample size of 85 was needed for an 80% power with a level of significance of 0.05. Data gathering was done by chart review. The primary outcome is PDPH. Data to be included: demographics, Diabetes Mellitus status, immunosuppression status, additional procedures needed, reason for LP, BMI, gender, ethnicity, physician vs APP (blinded) performing LP, needle type (20 vs 22 gauge), number attempts of needle entry, and history of PDPH. Secondary outcomes will include CSF leak and need for additional procedures. This project passed IRB approval. Note: The full chart review was not completed due to the issues with supine time documentation. Risk associations with PDPH were examined instead. Methods

Diabetes Mellitus is not known to be a risk factor for PDPH according to the literature. While it is likely that the results in this study were skewed by the higher proportion of headache history in the PDPH group, it is possible that Diabetes Mellitus could play a role in this disease state. This could be a future area of study. There is an ideal amount of supine time following dura puncturing procedures that yields lower PDPH rates. The reveal of unknown supine time charting was an unknown variable that could impact patient outcomes. Communication within a medical practice and proper documentation are two very important aspects of medical care that can lead to avoidance of adverse events such as PDPH. There was insufficient documentation in our patient population to statistically relate PDPH to supine time or any other risk factors. Another group of patients will be screened in 6 months to complete the study. This project unexpectedly gained a secondary role as quality improvement in a community-based practice.

Chart review revealed inadequate documentation of supine time in medical charting. Operative note charts commonly prescribed 1 hour of supine time, 3 hours of supine time, or no mention of supine time. The physicians in the Interventional Radiology group were surprised by this finding and were interested in adhering to a standardized amount of supine time. A standardized post-operative order set was created for dura puncturing procedures. In 6 months, another group of patients will be screened for eligibility for inclusion to complete the original study. In this patient population, there was found to be an increased risk for PDPH with diabetes mellitus status and a history of headaches.

References

Figure 1: Percent associations for patients who did suffer from PDPH. There were 12 patients in this group.

1. Bezov D, Lipton RB, Ashina S. Post-dural puncture headache: part I diagnosis, epidemiology, etiology, and pathophysiology. Headache. 2010 Jul;50(7):1144–52. 2. MacGrory B. Randomized Trial to Evaluate Optimal Recumbent Time after Lumbar Puncture (P2.185). Neurology. 2017;88(16 Supplement). 3. Kim SR, Chae HS, Yoon MJ, Han JH, Cho KJ, Chung SJ. No effect of recumbency duration on the occurrence of post-lumbar puncture headache with a 22G cutting needle. BMC Neurol. 2012 Jan 30;12:1. 4. Alstadhaug KB, Odeh F, Baloch FK, Berg DH, Salvesen R. Post-lumbar puncture headache. Tidsskr Nor Laegeforen. 2012 Apr 17;132(7):818–21. 5. Weinrich J, von Heymann C, Henkelmann A, Balzer F, Obbarius A, Ritschl PV, et al. [Postdural puncture headache after neuraxial anesthesia: incidence and risk factors]. Anaesthesist. 2020 Dec;69(12):878–85.

Acknowledgements

Special thanks to Heather Bendyk for providing statistical guidance for this project.

Figure 2: Percent associations for patients who did not suffer from PDPH. There were 57 patients in this group.

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2024 Research Recognition Day